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      Three Different Learning Curves Have an Independent Impact on Perioperative Outcomes After Robotic Partial Nephrectomy: A Comparative Analysis

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          Abstract

          Background

          Robot-assisted partial nephrectomy (RAPN) has become widely accepted, but its different underlying types of learning curves have not been comparatively analyzed to date. This study aimed to determine and compare the impact that the learning curve of the department, the console surgeon, and the bedside assistant as well as patient-related factors has on the perioperative outcomes of RAPN.

          Methods

          The study retrospectively analyzed 500 consecutive transperitoneal RAPNs (2007–2018) performed in a tertiary referral center by 7 surgeons and 37 bedside assistants. Patient characteristics and surgical data were obtained. Experience (EXP) was defined as the current number of RAPNs performed by the department, the surgeon, and the assistant. As the primary outcome, the impact of EXP and patient-related factors on perioperative outcomes were analyzed and compared. As the secondary outcome, a cutoff between “experienced” and “inexperienced” was defined. Correlation and regression analysis, receiver operating characteristic curve analysis, Fisher’s exact test, and the Mann–Whitney U test were performed, with p values lower than 0.05 denoting significance.

          Results

          The EXP of the department, the surgeon, and the assistant each has a major influence on perioperative outcome in RAPN irrespective of patient-related factors. Perioperative outcomes improve significantly with EXP greater than 100 for the department, EXP greater than 35 for the surgeon, and EXP greater than 15 for the assistant.

          Conclusions

          The perioperative results of RAPN are influenced by three different types of learning curves including those for the surgical department, the console surgeon, and the assistant. The influence of the bedside assistant clearly has been underestimated to date because it has a significant impact on the perioperative outcomes of RAPN.

          Electronic supplementary material

          The online version of this article (10.1245/s10434-020-08856-1) contains supplementary material, which is available to authorized users.

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          Most cited references25

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          Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery.

          Vincenzo Ficarra, Giacomo Novara, Silvia Secco … (2009)
          Besides clinical tumour size, other anatomical aspects of the renal tumour are routinely considered when evaluating the feasibility of elective nephron-sparing surgery (NSS). To propose an original, standardised classification of renal tumours suitable for NSS based on their anatomical features and size and to evaluate the ability of this classification to predict the risk of overall complications resulting from the surgery. We enrolled prospectively 164 consecutive patients who underwent NSS for renal tumours at a tertiary academic referral centre from January 2007 to December 2008. Open partial nephrectomy without vessel clamping. All tumours were classified by integrating size with the following anatomical features: anterior or posterior face, longitudinal, and rim tumour location; tumour relationships with renal sinus or urinary collecting system; and percentage of tumour deepening into the kidney. We generated an algorithm evaluating each anatomical parameter and tumour size (the preoperative aspects and dimensions used for an anatomical [PADUA] score) to predict the risk of complications. Overall rates of complication were significantly correlated to all the evaluated anatomical aspects, excluding clinical size and anterior or posterior location of the tumour. By multivariate analysis, PADUA scores were independent predictors of the occurrence of any grade complications (hazard ratio [HR] for score 8-9 vs 6-7: 14.535; HR for score ≥10 vs 6-7: 30.641). Potential limitations were the limited number of patients with T1b tumours included in the study and the lack of laparoscopically treated patients. Further external validation of the PADUA score is needed. The PADUA score is a simple anatomical system that can be used to predict the risk of surgical and medical perioperative complications in patients undergoing open NSS. The use of an appropriate score can help clinicians stratify patients suitable for NSS into subgroups with different complication risks and can help researchers evaluate the real comparability among patients undergoing NSS with different surgical approaches.
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            Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis.

            Ji Eun Choi, Ji Hye You, Dae Keun Kim … (2015)
            Robotic partial nephrectomy (RPN) is rapidly increasing; however, the benefit of RPN over laparoscopic partial nephrectomy (LPN) is controversial.
            Article 0 comments Cited 87 times – based on 0 reviews     Review now
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              The surgical learning curve for prostate cancer control after radical prostatectomy.

              Alwyn M Reuther, J. Pontes, James Eastham … (2007)
              The learning curve for surgery--i.e., improvement in surgical outcomes with increasing surgeon experience--remains primarily a theoretical concept; actual curves based on surgical outcome data are rarely presented. We analyzed the surgical learning curve for prostate cancer recurrence after radical prostatectomy. The study cohort included 7765 prostate cancer patients who were treated with radical prostatectomy by one of 72 surgeons at four major US academic medical centers between 1987 and 2003. For each patient, surgeon experience was coded as the total number of radical prostatectomies performed by the surgeon before the patient's operation. Multivariable survival-time regression models were used to evaluate the association between surgeon experience and prostate cancer recurrence, defined as a serum prostate-specific antigen (PSA) of more than 0.4 ng/mL followed by a subsequent higher PSA level (i.e., biochemical recurrence), with adjustment for established clinical and tumor characteristics. All P values are two-sided. The learning curve for prostate cancer recurrence after radical prostatectomy was steep and did not start to plateau until a surgeon had completed approximately 250 prior operations. The predicted probabilities of recurrence at 5 years were 17.9% (95% confidence interval [CI] = 12.1% to 25.6%) for patients treated by surgeons with 10 prior operations and 10.7% (95% CI = 7.1% to 15.9%) for patients treated by surgeons with 250 prior operations (difference = 7.2%, 95% CI = 4.6% to 10.1%; P<.001). This finding was robust to sensitivity analysis; in particular, the results were unaffected if we restricted the sample to patients treated after 1995, when stage migration related to the advent of PSA screening appeared largely complete. As a surgeon's experience increases, cancer control after radical prostatectomy improves, presumably because of improved surgical technique. Further research is needed to examine the specific techniques used by experienced surgeons that are associated with improved outcomes.
              Article 0 comments Cited 57 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Philip Zeuschner:
                ORCID: http://orcid.org/0000-0001-8898-6588
                philip.zeuschner@uks.eu
                Irmengard Meyer: irmengard.meyer@gmail.com
                Stefan Siemer: stefan.siemer@uks.eu
                Michael Stoeckle: michael.stoeckle@uks.eu
                Gudrun Wagenpfeil: gw@med-imbei.uni-saarland.de
                Stefan Wagenpfeil: sw@med-imbei.uni-saarland.de
                Matthias Saar: matthias.saar@uks.eu
                Martin Janssen: martin.janssen@ukmuenster.de
                Journal
                Journal ID (nlm-ta): Ann Surg Oncol
                Journal ID (iso-abbrev): Ann Surg Oncol
                Title: Annals of Surgical Oncology
                Publisher: Springer International Publishing (Cham )
                ISSN (Print): 1068-9265
                ISSN (Electronic): 1534-4681
                Publication date (Electronic): 24 July 2020
                Publication date PMC-release: 24 July 2020
                Publication date (Print): 2021
                Volume: 28
                Issue: 2
                Pages: 1254-1261
                Affiliations
                [1 ]GRID grid.11749.3a, ISNI 0000 0001 2167 7588, Department of Urology and Pediatric Urology, , Saarland University, ; Homburg/Saar, Germany
                [2 ]GRID grid.11749.3a, ISNI 0000 0001 2167 7588, Department of Medical Biometry, Epidemiology and Medical Informatics, , Saarland University, ; Homburg/Saar, Germany
                [3 ]GRID grid.16149.3b, ISNI 0000 0004 0551 4246, Present Address: Department of Urology and Pediatric Urology, , University Hospital of Munster, ; Münster, Germany
                Author information
                http://orcid.org/0000-0001-8898-6588
                Article
                Publisher ID: 8856
                DOI: 10.1245/s10434-020-08856-1
                PMC ID: 7801306
                PubMed ID: 32710272
                SO-VID: 11e47d5b-114f-45d3-a8d9-2f253fdd9ac8
                Copyright © © The Author(s) 2020
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 28 February 2020
                Date accepted : 15 June 2020
                Categories
                Subject: Urologic Oncology
                Custom metadata
                issue-copyright-statement © Society of Surgical Oncology 2021

                ScienceOpen disciplines: Oncology & Radiotherapy
                Data availability:
                ScienceOpen disciplines: Oncology & Radiotherapy

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